The correct diagnosis is an important condition for knowing the clinical manifestations, developmental patterns and characteristics, regression and prognosis of the disease, as well as the effectiveness of clinical treatment; of course, it is also necessary to have the scientific and technical knowledge of disease life, disease interpretation, as well as pharmacology and therapeutics.
The author has treated many such misdiagnosis cases in recent years, according to incomplete statistics, in 2010, there are no less than 10 cases, not including the online consultation through the good doctor website patients. Now a few typical cases will be cited even, and colleagues to discuss, to ensure that the doctor has a clear sense of the patient has accurate treatment.
I. Clinical cases
Case 1 Huang xx, male, 51 years old, train maintenance worker.
Complaint: right shoulder pain for two months, dysfunction for one month.
History: Two months ago, without any obvious cause, he had pain around the right shoulder, sometimes accompanied by pain radiating from the lateral neck and shoulder to the Quchi point, and could not sleep at night. One month later, he had difficulty lifting the affected shoulder, with occasional finger numbness and no dizziness or headache.
Past history: Two years ago, due to neck and shoulder back pain, external X-ray showed degenerative changes of the cervical spine.
Physical examination: cervical spine physiological curvature straightened, stiffer, middle section slightly curved to the right, right to left pushing pressure pain (+), left) (-), right brachial plexus nerve pulling test (+), left (-), intervertebral foraminal extrusion test (-), right cervical shoulder back soft tissue tension increased, affected shoulder supination: front 100 degrees, side 70 degrees, internal rotation backward curvature, tiger mouth up to the fourth lumbar vertebra.
Opinion: cervical spondylosis (nerve root type)
Secondary periarthritis stage 2, severe adhesions, inflammatory adhesions and more
Case 2 Huang xx,female, 46 years old, clothing salesman.
Complaint: left shoulder pain for three months and dysfunction for one month.
History: The patient had been playing mahjong for a long time for many years, and had left shoulder pain with dysfunction for about one month since three months ago. The increased symptoms were obviously related to prolonged head bowing, with occasional radiating pain in the upper shoulder and arm, without dizziness and headache or finger numbness. He was diagnosed with frozen shoulder after a cervical spine photograph showed cervical osteophytes. She was treated with anti-inflammatory and pain relief tablets, infrared rays and compresses.
Past history: no special condition.
Physical examination: cervical spine physiological curvature straight, stiffer, 3rd,4th,5th vertebrae mildly curved to the left, pushing pressure pain to the right (+), left brachial plexus nerve pull test (+/-), intervertebral foraminal compression test (-). Affected shoulder supination: 110 degrees anteriorly, 75 degrees laterally, internally rotated backward bending, tiger mouth reaching the 3rd lumbar vertebra.
Opinion: cervical spondylosis (neurogenic type differentiated from cervical type)
Secondary periarthritis stage 2, severe adhesions, adhesions predominant
Case 3 Tanxx, female, 54 years old, post office cadre.
Complaint: stroke for 1 year, right shoulder pain for 11 months, left shoulder pain for 6 months.
History: The patient had a history of wind heart disease for more than 20 years. 1 year ago, he suffered a cerebral embolism, resulting in incomplete hemiparesis of the right limb, and was treated in a tertiary hospital in the city, and felt pain around the right shoulder for about one month. He was treated at a tertiary hospital in the city and felt pain around his right shoulder for about a month. After a heart valve operation six months later, he developed left shoulder pain again, the exact diagnosis and treatment of which is unknown.
Past history: No other important medical history except the above.
Physical examination: incomplete hemiparesis on the right side, general condition is still good, neck is soft, physiological bending exists, mild atrophy of the muscles around both shoulders, mild to moderate subluxation of the right shoulder joint. The right shoulder joint is mildly to moderately subluxated. The front supination is 120 degrees, the side supination is 80 degrees, the internal rotation is backward bending, and the tiger mouth reaches the 3rd lumbar vertebra; the left shoulder supination is 135 degrees, the side supination is 85 degrees, the internal rotation is backward bending, and the tiger mouth reaches the 2nd lumbar vertebra.
Opinion: wind heart disease, post-operative heart valve
sequelae of cerebral embolism, incomplete hemiparesis of the right limb.
Secondary periarthritis stage 2, severe adhesions, adhesions predominant, right shoulder stroke complication, left shoulder post-thoracotomy reflex
II. Summary of cases
Both case 1 and case 2 above have one thing in common, namely, periapical pain, followed by dysfunction and moderate adhesions, which is coolly resembling the clinical manifestation of frozen shoulder. The diagnosis of periarthritis was made at the external hospital, and the patient was routinely treated with the medication and physical therapy for periarthritis. However, it is not uncommon to identify the disease by age, cause, symptoms, signs, and x-ray examination of the neck and shoulder. However, what is different for this disease is that the shoulder pain is radiating, or accompanied by finger numbness, and on physical examination there is significant cervical deformity and stiffness, with scoliosis, all in the direction of the affected shoulder side. Similarly, the finger numbness, positive signs and test signs were all on the affected shoulder side. In contrast, in case 3, although there are symptoms and signs of frozen shoulder, there are no cervical spine factors that can trigger the disease, but other factors that can trigger the symptoms of frozen shoulder, not primary.
III. Discussion and experience
Periarthritis, or frozen shoulder, is an independent disease, the cause of which is not yet clear, and its symptoms and signs are similar to those of other disorders. Among the secondary disorders, the pathogenesis of the disease has not yet been determined. The methods of examination and diagnostic criteria for shoulder adhesions are still vague. Throughout the textbooks, literature, and books, we think that Professor Jin Dekang, a professor of rehabilitation, described it best and very honestly. This is because the choice of treatment for secondary frozen shoulder varies with the nature of the primary, which is the basis for the ideas in this article. For example, if it is secondary to trauma, the treatment is to treat the soft tissue injury; if it is infectious, it is to treat the infection directly; if it is reflex, it is to terminate or reduce the stimulation treatment depending on the factor. In my 20 years of observation in the specialty, I have found that there is a special phenomenon in the human shoulder, not most people of course, that is, the shoulder may cause or exacerbate the secondary shoulder condition after a variety of secondary stimuli to the body. Mr. Jin has also mentioned in his book that there are cases of “frozen shoulder caused by bee stings on the hand,” and that “some patients with systemic diseases and after thoracic or abdominal surgery may also suffer from frozen shoulder”. We have also seen patients with primary and secondary frozen shoulder treated with periapical medications and intravenous IV infusions from time to time, and found that their condition was aggravated and they developed periapical muscle atrophy. It is rarely reported in the literature, and according to half of the common knowledge of disease pathology, it may be an individual sensitive organism that reflexively causes persistent spasm of local tissues after a stronger and/or sustained paracrine stimulus. Complex pathological and biochemical changes such as inflammatory response, these need to be further investigated.
In this paper, cervical secondary shoulder refers to the pathological condition of cervical spine, which triggers periarthritis. The clinical manifestations are all periarthral pain, followed by shoulder joint dysfunction with shoulder adhesions, but these patients always have obvious positive features of cervical spine, often with long latent cervical spine pathology, and mostly occur in patients with neurogenic, cervical, or mixed type of the disease. If CT or MRI is performed, it will facilitate clinical thinking and judgment. In particular, the incidence of cervical spondylosis is particularly high today, and some domestic scholars have calculated that the number of outpatient visits in recent years has exceeded that of lumbar spondylosis. The human intervertebral disc starts to degenerate around the age of 20, reducing water, elasticity, and volume, and people will experience cervical spine disease and its complications due to various bad habits and postures in long-term daily work or life. For example, cervical spine morphology variation, vertebral instability, disc bulge and herniation, bone proliferation in certain locations, etc., direct compression, stimulation, reflexes (e.g. sinus spinal nerve reflex), etc. of these factors. Of course, the same pathologic situation varies greatly from individual to individual, and the pathogenesis is complex. From our clinical practice over the years, we have observed that those patients with cervical spine with obvious variation, such as lateral curvature, stiffness of the cervical segment, limitation of motion, and ipsilateral pressure pain, can almost be diagnosed with cervical secondary shoulder, even if the positive cervical spine test is not very obvious. . For many years, we have been treating patients with cervical secondary shoulder with two sets of programs, focusing on the pathological changes in the neck and giving intermittent remote traction and relaxation, depending on the situation, and we do get good results in most cases.
For the sake of better communication, I would like to explain the table of the differentiation points of common cervical secondary shoulder and frozen shoulder, due to the shortage of time and limited level, mistakes and omissions are inevitable, I sincerely hope that our colleagues will correct us.